Agent Details
Licensed Agent Name
D.B.A. (if applicable)
Federal Tax I.D. #
Agency License # State Held -+
Date Agency Established
Date of Last Change in Ownership
Is This The Home Office? YesNo
Number of Branch Offices
Type of Business ProprietorshipPartnershipCorporationLLC
Street AddressCityStateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificZip Code
Same as previousStreet AddressCityStateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificZip Code
Phone Fax Email
Name of Agency Principals
Main Contact Title Phone
Years in Business Number of Licensed Producers
Annual Gross Written Premium $ $ Commercial Lines $ $ Personal Lines $ $
Annual Amount Financed $ $ Average Policy Size $ $ Current Premium Finance Company $ $
Notice of CancellationEmailMailBoth
Email
Notice of ReinstatementEmailMailBoth
Disbursement ReportEmailMailBoth
Missing Policy # ReportEmailMailBoth
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